Surgeon Years Of Experience Research Articles

CASEMIX study: Assessment of patient factors influencing the subprocedure duration of trauma/orthopaedic surgeries

IntroductionThe social and financial burdens of the operative environment remains to be a major problem in modern society. We analyse the impact of the introduction and application of a perioperative cloud system that cross-analyzes the pre-/intraoperative risks to minimize surgical time and maximize operation theater efficiency through improved planning. MethodsTCC-CASEMIX© was introduced to our Department of Trauma Surgery of the University of Szeged to objectively measure intraoperative time durations according to each essential subprocedure. The study is largely divided into pre-operative assessments and intraoperative measurements. Patient data (age, sex, and ethnicity etc.) was registered preoperatively, and the expected time per each essential intraoperative step (skin incision, reduction, fixation etc.) was entered. The steps were then timed intraoperatively by surveyors, and postoperative cross analysis was performed. Our study was divided into two phases; phase 1, the surveying of general trauma / orthopedic cases, and phase two; the examination of high volume surgeries. ResultsAcute cases of Open Reductions and Internal Fixation (ORIF) procedures depended heavily on the presentation of the fracture, and no clear correlations in the risk factors were found. Arthroscopies were a short, high-volume procedure, but there was a large difference between the surgeon's estimates and the operation duration. In high volume surgeries, although individual factors only slightly influenced surgical duration, patient cohort stratification led to a better understanding of factors that impact surgeries, namely the combination of BMI and surgeon years of experience. While the average (Intraoperative Duration) seemed to increase with BMI, younger surgeons were more influenced by the patients BMI. ConclusionA data filtering algorithm-assisted cloud system can be a reliable way to facilitate the planning of operating theater schedules. Patient stratification according to BMI and surgeon years of experience seems to affect intraoperative duration significantly, and the understanding of the risks and intraoperative steps has the potential to forecast surgeries with high precision.

Factors affecting operating room scheduling accuracy for primary and revision total hip arthroplasty: a retrospective study.

Optimizing operating room (OR) scheduling accuracy is important for OR efficiency, meeting patient expectations, and maximizing value for health systems. However, limited data exist on factors influencing the precision of Total Hip Arthroplasty (THA) OR scheduling. This study aims to identify the factors influencing the accuracy of OR scheduling for THA. A retrospective review of 6,072 THA (5,579 primary THA and 493 revision THA) performed between January 2020 and May 2023 at an urban, academic institution was conducted. We collected baseline patient characteristics, surgeon years of experience, and compared actual wheels in to wheels out (WIWO) OR time against scheduled OR time. Significant scheduling inaccuracies were defined as actual OR times deviating by at least 15% from scheduled OR times. Logistic regression analyses were employed to assess the impact of patient, surgeon, and intraoperative factors on OR scheduling accuracy. Using adjusted odds ratios, primary THA patients who had a lower BMI and surgeons who had less than 10 years of experience were associated with overestimation of OR time. Whereas, higher BMI, younger age, general anesthesia, non-primary osteoarthritis indications, and afternoon procedure start times were linked to underestimation of OR time. For revision THA, lower BMI and fewer components revised correlated with overestimated OR time. Men, higher BMI, more components revised, septic indication for surgery, and morning procedure start times were associated with underestimation of OR time. This study highlights several critical patient, surgeon, and intraoperative factors influencing OR scheduling accuracy for THA. OR scheduling models should consider these factors to enhance OR efficiency.

Use of paralytic agents during the operative treatment of type III supracondylar humerus fractures in children: A single-center investigation and survey of Pediatric Orthopaedic Society of North America members

BackgroundParalytic agents are occasionally used during the surgical treatment of type III (OTA 13A2) supracondylar humerus fractures (SCHFx) in children depending on surgeon preference. Paralytic agents create a neuromuscular blockade and therefore may potentially help with ease of fracture reduction. Controversy regarding the use of a paralytic agent as an adjunct to anesthesia exists due to potential associated adverse drug reactions, including prolonged paralysis, cardiovascular effects, or electrolyte abnormalities.The purpose of this study was to investigate intraoperative paralytic use in pediatric type III SCHFx and to report survey responses of members of the Pediatric Orthopaedic Society of North America (POSNA) on paralytic use in SCHFx management. MethodsA retrospective chart review identified 319 type III SCHFx treated at our institution (January 2016-May 2019). Patients were assigned to three groups: Group 1, surgical treatment without a paralytic agent (n=240); Group 2, treatment with rocuronium (n=43); Group 3, treatment with succinylcholine (n=36). POSNA members were surveyed regarding paralytic use intraoperatively for type III SCHFx (November–December 2021) on paralytic use frequency, request for paralytics, reversal agent use, average time to surgery after injury and/or presentation, effect of time to surgery after injury and/or presentation on when to use a paralytic, annual number of SCHFx surgeries performed, awareness of paralytic complications, and years of surgeon experience. Statistical analysis was performed. ResultsAverage patient age was 5.2±2.2 years. Group 2 had significant increases in anesthesia duration, surgical duration, fluoroscopic time, and radiation exposure compared to Group 1. Group 2 had a higher conversion rate to open reduction than other groups. No statistically significant difference was found among groups in terms of sex, body mass index (BMI), laterality, radiographic measurements, or rates of open procedures or complications. Survey results indicated 32% (24/76) routinely use paralytics during closed reduction maneuvers; 71% (17/24) request administering paralytics at the beginning/before the case; and 33% (8/24) use paralytics in all type III SCHFx. ConclusionsSurgeons at our center reported paralytic use for closed reduction in 25% of patients; similarly, one-third of POSNA survey respondents reported paralytic use during operative management. Although paralytic agents are used during the treatment of supracondylar humerus fractures in children this study was unable to demonstrate an association of advantageous outcomes, such as shorter surgical times. Routine paralytic use to facilitate closed reduction of supracondylar humerus fractures in children warrants further study. Level of EvidenceLevel III, Retrospective chart review; Therapeutic study

(1217) - Surgeon Years of Experience and Survival After Heart Transplantation

(1217) - Surgeon Years of Experience and Survival After Heart Transplantation

Paper 42: A Novel Machine Learning (ML) Algorithm to Predict Outcomes after Revision ACLR (rACLR) in the Multicenter Anterior Cruciate Ligament Reconstruction Study (MARS) Cohort

Objectives: The multicenter anterior cruciate ligament reconstruction study (MARS) Group has implicated several factors that influence revision anterior cruciate ligament (rACLR) outcomes. As machine learning (ML) becomes increasingly utilized in the orthopaedic literature, the application of ML methodology to MARS cohort data presents a valuable opportunity to translate data into patient-specific insights. This study sought to apply novel ML methodology to the MARS cohort data in order to determine 1) an optimal predictive model of rACLR graft failure and 2) features that are most predictive of rACLR graft failure in context of the predictive model. Methods: The MARS Group of 83 surgeons and 52 sites prospectively enrolled a cohort of patients undergoing rACLR. Patients were followed up at 2 and 6 years postoperatively regarding patient-reported outcomes (PROs), additional surgeries, and incidence of graft failure. Surgeon reported intraoperative findings and preoperative radiographic measures were obtained. Data was preprocessed and 381 demographic, clinical, and surgical features were used to build five machine learning models predictive of graft failure at 6 years postoperatively. Models used included traditional logistic regression (LR), XGBoost, Gradient Boosting, Random Forest, and a validated ensemble algorithm, AutoPrognosis (AP). Validated performance metrics for binary outcome prediction models were used to determine discriminative power and calibration. Individual feature importance was calculated for the highest performing models using partial dependence and perturbation-based feature importance. Results: The cohort included 831 patients who completed six year follow up, and 5.8% (n=48) of whom experienced graft failure. While all models had moderate to good concordance, AP demonstrated the highest discriminative power compared to other models (Model: AUROC | AP: 0.722 | Random Forest: 0.621 | Gradient Boosting: 0.654 | XGBoost: 0.690 | Logistic Regression: 0.630). The AP model was well-calibrated, with calibration scores similar to the other studied models (Model: Brier Score | AP: 0.054 | Random Forest: 0.054 | Gradient Boosting: 0.059 | XGBoost: 0.059 | Logistic Regression: 0.102). Features deemed important for AP differ from those for LR model performance. For AP, partial dependence feature importance calculations demonstrated the following top five contributors to model predictive ability: surgeon years of experience, prior femoral tunnel position measured via preoperative radiograph, compromised prior ACLR femoral tunnel position and size, and baseline patient age. Similarly, AP perturbation-based calculations showed the following top five features that contribute most to the AUROC performance: baseline patient age, current ACLR graft type, years since previous ACLR, prior ACLR femoral tunnel position, and prior tibial tunnel position on sagittal view preoperative radiographs. Perturbation-based calculations showed the following top five features that contribute most to the AUPRC performance: current ACLR graft type, baseline patient age, prior tibial tunnel position on sagittal view preoperative radiographs, previous ipsilateral medial meniscus repair, and baseline SF-36 subscale scores for patient vitality. Other leading contributors to model predictive ability included baseline PROs including SF-36 subscale scores for physical function, mental health and composite mental health, KOOS quality of life, WOMAC pain, and MARX activity rating scores. Conclusions: Of the studied models in this preliminary analysis, AP appears to most accurately predict rACLR graft failure. These findings build on prior studies, identifying key surgical, clinical, radiographic, and patient-reported factors contributing to the model’s ability to predict rACLR graft failure at 6 years postoperatively. Further work includes creation of a clinical risk calculator using important feature inputs, and the use of survival modeling to determine risk scores at various postoperative time points.

Effect of surgeon years of experience on patient outcomes following emergency laparotomy: retrospective cohort study

Effect of surgeon years of experience on patient outcomes following emergency laparotomy: retrospective cohort study

A Survey of IPEG-Middle East Chapter members to ascertain their perceptions of, and changes to, the Nissen's wrap design and the outcomes

BackgroundNissen's description of fundoplication has proven seminal in our understanding of anti-GERD surgeries. This survey aimed to ascertain the perceptions of, and changes to, the Nissen's wrap design among the IPEG-ME surgeons and their outcomes.MethodsDuring the months of February and March 2021, all IPEG-ME members were contacted via WhatsApp and asked to complete an anonymous online survey. Google Forms was used as the platform for the survey. Responses were collected over a four-week period.ResultsFrom a total of 99 IPEG-ME members, 51 practicing pediatric surgeons from eight countries reported seven separate conceptions for the original Nissen wrap design. With more surgeon years of experience, not hospital annual volume, the percentage of surgeons who choose to preserve the short gastric vessels at laparoscopic Nissen fundoplication increased from 10 to 25%. Moreover, transmigration and reoperation rates were cut in half, while dysphagia rates doubled as surgeon years of experience increased from under 10 to over 30.ConclusionOwing to haziness, specialized surgeons may have expressed non-identical thoughts of the original description of a commonly employed procedure. Wrap transmigration and reoperation rates were cut in half, while dysphagia rates doubled as surgeon years of experience increased from under 10 to over 30. It seems reasonable to standardize the wrap design based on the components' justifications rather than surgeons’ preferences.

776 Patient Outcomes Vary with Surgeons’ Experience Following Emergency Laparotomy: An Observational Study

Abstract Aim There is some evidence that patient outcomes for surgeons improve with years of experience. We aimed to investigate the relationship between surgeon experience and patient outcomes following an emergency laparotomy in a large sample of the UK National Emergency Laparotomy Audit (NELA) database. Method A 5-year retrospective observational study was undertaken using data extracted from NELA for patients who underwent emergency laparotomies at a large UK multi-site NHS Trust. The association between 30-day mortality and surgeon years of experience was investigated using logistic regression, adjusted for ASA grade, patient age and gender, Index of Multiple Deprivation (IMD) score, and time of surgery. Results There were 3153 patients with a median age of 66 (IQR 51–76), and 49.4% were male. Patients in the group who died within 30 days were more likely to be older, have a higher ASA score, and have an operation during the night. Increasing years of surgeon experience, patient age, and ASA were all significantly associated with increased odds ratio of death within 30-days. Conclusions Increasing years of surgical experience appears to be related to worse patient outcomes for an emergency laparotomy. This is likely due to surgeons taking on more complex and challenging cases as their career progresses. Further explorations of how surgeons’ activity changes over their full career are warranted.

Predictors of Complication Following Cleft Lip and Palate Surgery in a Low-Resource Setting: A Prospective Outcomes Study in Nicaragua.

Higher rates of postoperative complication following cleft lip or palate repair have been documented in low resource settings, but their causes remain unclear. This study sought to delineate patient, surgeon, and care environment factors in cleft complications in a low-income country. Prospective outcomes study. Comprehensive Cleft Care Center. Candidate patients presenting for cleft lip or palate repair or revision. Patient anthropometric, nutritional, environmental and peri- and post-operative care factors were collected. Post-operative evaluation occurred at standard 1-week and 2-month postoperative intervals. Complication was defined as fistula, dehiscence and/or infection. Among 408 patients enrolled, 380 (93%) underwent surgery, of which 208 (55%) underwent lip repair (124) or revision (84), and 178 (47%) underwent palate repair (96) or revision (82). 322 (85%) were evaluated 1 week and 166 (44%) 2 months postoperatively. 50(16%) complications were identified, including: 25(8%) fistulas, 24(7%) dehiscences, 17(5%) infections. Mid-upper arm circumference (MUAC) ≤12.5 cm was associated with dehiscence after primary lip repair (OR = 28, p = 0.02). Leukocytosis ≥11,500 on pre-operative evaluation was associated with dehiscence (OR = 2.51, p = 0.04) or palate revision fistula (OR = 64, p < 0.001). Surgeons who performed fewer previous-year palate repairs had higher likelihood of palate complications, (OR = 3.03, p = 0.01) although there was no difference in complication rate with years of surgeon experience or duration of surgery. Multiple patient, surgeon, and perioperative factors are associated with higher rates of complication in a low-resource setting, and are potentially modifiable to reduce complications following cleft surgery.

An Observational Survey of Nail and Skin of Spine Surgeons-Possible Damage by Occupational Ionizing Radiation Exposure.

Introduction Orthopedic surgeons are exposed to ionizing radiation daily. With the increase in the number of minimally invasive surgery performed under X-ray fluoroscopy, radiation exposure to unprotected fingers will increase. Although the effect of high dose radiation exposure is known, the long-term effect of exposure to low doses is unclear. This study aims to investigate damage to the nail and skin on the thumbs of spine surgeons via occupational ionizing radiation exposure. Methods Forty male spine surgeons (group S) and 40 males of the same age group who were not exposed to radiation (controls; group C) were included. Using a scoring system, we evaluated the damage to the fingernail and skin of the bilateral thumb. Scoring was based on fingernail pigmentation (melanonychia), fingernail crack, and periungual dermatitis status. We investigated the number of examinations and operations under radiation exposure in the last 3 months. Results Group S had 17.83 (3-28) years of surgeon experience. In group S, the dominant side scored significantly higher than the non-dominant side; however, there was no dominant vs. non-dominant difference in group C. Only the dominant side had a significantly higher score in group S than in group C. In group S, surgeon experience and the score of the dominant side were significantly correlated; however, for the non-dominant side of group S and both thumbs of group C, no correlation was observed. The kappa coefficients for fingernail pigmentation, fingernail crack, and periungual dermatitis status were 0.458, 0.248, and 0.612, respectively. The average number of examinations and operations under radiation exposure was 11.89 ± 9.04 (0-30) and 26.34 ± 14.67 (1-63), respectively. Conclusions The dominant side in group S had a significantly higher score than the non-dominant side in group S and the dominant side in group C, suggesting the possibility of radiation damage to the dominant side in group S.

The Impact of Post-Graduate Year of Primary Surgeon on Technical Performance Score in Tetralogy of Fallot Repair.

The aim of this study was to assess the impact of surgeon years of experience on clinical outcomes of tetralogy of Fallot (TOF) repair using technical performance score (TPS), and to investigate the possibility of safe operations by surgical trainees.Methods and Results:We assessed the cases of 159 consecutive patients who underwent TOF repair between 2001 and 2015. Thirteen different primary surgeons performed operations with 41 different first assistants. The primary surgeon and first assistant mean postgraduate years were 19.1±5.1 years (range, 5.7-31.6 years) and 11.2±6.3 years (range, 3.2-36.3 years), respectively. TPS was assigned using pre-discharge echocardiography based on original criteria. Logistic regression analysis was used to examine the factors associated with TPS. TPS could be scored for all patients, 16 of whom were graded as having optimal (10%), 119 as adequate (75%), and 24 as having inadequate (15%) TPS. None of the preoperative and perioperative variables affected TPS. Although neither the primary surgeon nor the first assistant postgraduate years was associated with TPS independently, total primary surgeon and first assistant postgraduate years correlated with TPS (OR, 1.07; 95% CI: 1.01-1.13, P=0.031). Primary surgeon postgraduate years was not associated with TPS for TOF repair. TOF repair can be performed adequately and safely by surgical trainees under the support of highly experienced supervisors.

Accuracy and Reliability of the Visual Assessment of Patellar Tracking

Background: Abnormal patellar tracking is described as a “J-sign” when the patella exhibits excessive lateral displacement during active knee extension. Purpose: To determine (1) the accuracy and reliability of the visual assessment of patellar tracking when viewed by surgeons with patellofemoral expertise and (2) whether surgeon experience (in years) correlates with the ability to accurately identify the presence and severity of patellar maltracking. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: Using a web-based assessment, 32 orthopaedic surgeon members of the International Patellofemoral Study Group determined the presence or absence of maltracking (≥2 quadrants of lateral translation) in 10 single-knee videos of patients with patellar instability during active knee extension (qualitative analysis). Surgeons then graded patellar tracking in 20 single-knee videos as follows: 0 (<1 patellar quadrant of lateral translation), 1 (1 to <2 quadrants), 2 (2 to <3 quadrants), or 3 (≥3 quadrants) (quantitative analysis). Responses were compared with a previously described grading system using patellar bisect offset measured with 4-dimensional computed tomography. We evaluated the association between number of years of surgeon experience and the ability to correctly identify and grade patellar tracking. A total of 22 surgeons repeated the survey 3 months later, and their answers were matched to the first survey, allowing for assessment of intraobserver reliability. Results: In the qualitative analysis, surgeons correctly identified videos as showing patellar maltracking 68% of the time (κ = 0.45). In the quantitative analysis, 53%, 51%, 48%, and 68% of surgeons correctly identified maltracking of grades 3, 2, 1, and 0, respectively (κ = 0.42). Surgeon experience did not correlate with ability to identify the presence (P = .59) or grade (P = .35) of patellar maltracking. Respondent answers from the second survey demonstrated inadequate intraobserver reliability (κ = 0.48). Conclusion: Using visual assessment alone, surgeons correctly identified patellar maltracking in approximately two-thirds of videos and correctly graded patellar maltracking in half. Inter- and intraobserver reliability were inadequate to support the use of visual assessment alone for detecting the presence or grade of patellar maltracking. Surgeon experience did not correlate with ability to identify the presence or grade of patellar maltracking.

The Intricate Association Between Case Volume and Years of Practice Experience on Open Abdominal Aortic Aneurysm Repair

Widespread adoption of endovascular aneurysm repair has led to a consequential national decline in open aortic repair (OAR), affecting both vascular surgery trainees and established surgeons alike. Whereas the volume-outcome relationship has been studied extensively, little remains known about the complex interaction of surgeon experience vs case volume on patient selection, procedural characteristics, and postoperative complications associated with OAR. The purpose of this analysis was to define the interaction between surgeon years of experience and annual case volume on OAR outcomes.

Wiser with Age? Increased Per-Surgeon Elderly Patient Volume is Associated with Lower Postinjury Complications

We hypothesize that higher elderly patient volume per trauma surgeon is associated with fewer clinical complications. This is a retrospective cohort study which included elderly patients admitted to trauma surgery service within a five-year period, from 2009 to 2013, at two Level I trauma centers in Florida. Trauma surgeons were stratified into three groups depending on patient volume. Primary outcomes were postinjury complications and in-hospital mortality, and secondary outcomes were hospital length of stay (LOS), intensive care unit LOS, and ventilator days. A total of 2379 elderly patients were included in this study. Elderly patient volume per surgeon did not significantly differ based on years in practice after fellowship (P = 0.88). The higher volume group had lower incidence of complications (15% complication rate, P = 0.02), compared with the average and low-volume group (18.1 and 21%, respectively), and had significantly lower rates of acute respiratory failure (P = 0.04) and acute renal failure (P = 0.004). In-hospital mortality was not affected by volume. Hospital LOS was decreased in the higher volume group (mean LOS 7.4 days, P < 0.001). There appears to be a relationship between elderly patient volume and outcome, independent of surgeon years of experience.

Higher surgeon annual volume, but not years of experience, is associated with reduced rates of postoperative complications and reoperations after open abdominal aortic aneurysm repair

ObjectiveVolume-outcome relationships for open abdominal aortic aneurysm (AAA) repair have received less attention in publicly funded health systems. Furthermore, the roles of surgeon seniority (years of experience) and composite volume (encompassing all major arterial cases) on outcomes after open AAA repair are less well known. We sought to determine the effects of surgeon volume, surgeon years of experience, and composite volume on outcomes after elective open AAA repairs performed in Ontario, Canada. MethodsUsing a population-based, prospectively collected health administrative database, all elective open AAA repairs occurring in the province of Ontario from 2005 to 2014 were identified. Surgeon annual volume was classified by quintiles, with the highest volume quintile acting as the reference category. Multivariable logistic regression modeling was used, adjusting for patient factors (age, sex, comorbidities, year of procedure, income) to investigate the relationship between surgeon annual volume and 30-day mortality, 30-day major complications, 30-day reoperations, 1-year mortality, and 1-year reoperations (related to index procedure). The potential effects of annual surgeon composite volume and surgeon years of experience on postoperative outcomes were also explored. ResultsA total of 7211 elective open AAA repairs performed by 101 surgeons were identified between 2005 and 2014. Most of the operations were performed by vascular surgeons (81.5%), followed by cardiac (12.1%) and general surgeons (6.1%). Median number of procedures in the lowest quintile group was 3 repairs/y, whereas the highest quintile group performed 54 repairs/y. Overall 30-day mortality was 3%. No difference in mortality was detected in comparing the lowest with the highest volume groups (1.89% vs 3.01%; adjusted odds ratio [OR], 0.60; 95% confidence interval [CI], 0.27-1.33). The lowest volume group exhibited a higher 30-day complication rate (28.0% vs 20.4%; OR, 1.54; 95% CI, 1.15-2.06) and 30-day reoperation rate (10.53% vs 6.73%; OR, 1.64; 95% CI, 1.13-2.38) compared with the highest volume group. No effect of surgeon volume on 1-year mortality or 1-year reoperation was observed. Similarly, composite volume and surgeon years of experience were not associated with postoperative outcomes. ConclusionsIn a single-payer system with a relatively high number of open AAA repairs/surgeon per year, surgeon annual volume had no effect on postoperative mortality but was associated with lower postoperative complication and reoperation rates.

Meniscal and Articular Cartilage Predictors of Clinical Outcome After Revision Anterior Cruciate Ligament Reconstruction

Background: Revision anterior cruciate ligament (ACL) reconstruction has been documented to have worse outcomes compared with primary ACL reconstructions. Purpose/Hypothesis: The purpose of this study was to determine if the prevalence, location, and/or degree of meniscal and chondral damage noted at the time of revision ACL reconstruction predicts activity level, sports function, and osteoarthritis symptoms at 2-year follow-up. The hypothesis was that meniscal loss and high-grade chondral damage noted at the time of revision ACL reconstruction will result in lower activity levels, decreased sports participation, more pain, more stiffness, and more functional limitation at 2 years after revision surgery. Study Design: Cohort study; Level of evidence, 2. Methods: Between 2006 and 2011, a total of 1205 patients who underwent revision ACL reconstruction by 83 surgeons at 52 hospitals were accumulated for study of the relationship of meniscal and articular cartilage damage to outcome. Baseline demographic and intraoperative data, including the International Knee Documentation Committee (IKDC) subjective knee evaluation, Knee injury and Osteoarthritis Outcome Score (KOOS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Marx activity score, were collected initially and at 2-year follow-up to test the hypothesis. Regression analysis was used to control for age, sex, body mass index, smoking status, activity level, baseline outcome scores, revision number, time since last ACL reconstruction, incidence of having a previous ACL reconstruction on the contralateral knee, previous and current meniscal and articular cartilage injury, graft choice, and surgeon years of experience to assess the meniscal and articular cartilage risk factors for clinical outcomes 2 years after revision ACL reconstruction. Results: At 2-year follow-up, 82% (989/1205) of the patients returned their questionnaires. It was found that previous meniscal injury and current articular cartilage damage were associated with the poorest outcomes, with prior lateral meniscectomy and current grade 3 to 4 trochlear articular cartilage changes having the worst outcome scores. Activity levels at 2 years were not affected by meniscal or articular cartilage pathologic changes. Conclusion: Prior lateral meniscectomy and current grade 3 to 4 changes of the trochlea were associated with worse outcomes in terms of decreased sports participation, more pain, more stiffness, and more functional limitation at 2 years after revision surgery, but they had no effect on activity levels. Registration: NCT00625885

Use of Preoperative Magnetic Resonance Imaging for Breast Cancer: A Canadian Population-Based Study.

Contrary to practice guidelines, breast magnetic resonance imaging (MRI) is commonly used in the preoperative evaluation of women with breast cancer. While existing literature has found little benefit to MRI in most patients, potential downstream consequences associated with breast MRI are not well described. To describe patterns of preoperative breast MRI utilization in a health care system with universal insurance and its association with downstream investigations and clinical outcomes. This was a population-based retrospective cohort study using administrative heath care databases in Ontario, Canada (2012 population, 13.5 million) over 14 geographic regions were evaluated within the data set. Participants comprised 53 015 patients with primary operable breast cancer treated from 2003 to 2012. Use of preoperative breast MRI by year, geographic region, and breast cancer stage. Postdiagnosis imaging, biopsy, and short-term surgical outcomes were also evaluated between those who did and did not receive MRI. Overall, 14.8% of patients (7824 of 53 015) had a preoperative MRI. During the 10-year study period, MRI use increased across all stages by 8-fold (from 3% to 24%; P < .001 for trend). Factors associated with MRI use were younger age, higher socioeconomic status, higher Charlson comorbidity score, surgery performed in a teaching hospital, and fewer years of surgeon experience. Multivariate analyses showed that preoperative breast MRI was associated with higher likelihood of the following: postdiagnosis breast imaging (odds ratio [OR], 2.09; 95% CI, 1.92-2.28), postdiagnosis breast biopsies (OR, 1.74; 95% CI, 1.57-1.93), postdiagnosis imaging to assess for distant metastatic disease (OR, 1.51; 95% CI, 1.42-1.61), mastectomy (OR, 1.73; 95% CI, 1.62-1.85), contralateral prophylactic mastectomy (OR, 1.48; 95% CI, 1.23-1.77), and a greater than 30-day wait to surgery (OR, 2.52; 95% CI, 2.36-2.70) (all ORs are adjusted). Preoperative breast MRI use has increased substantially in routine clinical practice and is associated with a significant increase in ancillary investigations, wait time to surgery, mastectomies, and contralateral prophylactic mastectomies.

The Relationship Between Extent of Thyroid Cancer Surgery and Use of Radioactive Iodine

By linking surgeon surveys to the National Cancer Database, we found that surgeons' tendency to perform more extensive thyroid resection is associated with greater use of radioactive iodine for stage I thyroid cancer. To determine the relationships between surgeon recommendations for extent of resection and radioactive iodine use in low-risk thyroid cancer. There has been an increase in thyroid cancer treatment intensity; the relationship between extent of resection and medical treatment with radioactive iodine remains unknown. We randomly surveyed thyroid surgeons affiliated with 368 hospitals with Commission on Cancer-accredited cancer programs. Survey responses were linked to the National Cancer Database. The relationship between extent of resection and the proportion of the American Joint Committee on Cancer stage I well-differentiated thyroid cancer patients treated with radioactive iodine after total thyroidectomy was assessed with multivariable weighted regression, controlling for hospital and surgeon characteristics. The survey response rate was 70% (560/804). Surgeons who recommend total thyroidectomy over lobectomy for subcentimeter unifocal thyroid cancer were significantly more likely to recommend prophylactic central lymph node dissection for thyroid cancer regardless of tumor size (P < 0.001). They were also more likely to favor radioactive iodine in patients with intrathyroidal unifocal cancer ≤1 cm (P = 0.001), 1.1-2 cm (P = 0.004), as well as intrathyroidal multifocal cancer ≤1 cm (P = 0.004). In multivariable analysis, high hospital case volume, fewer surgeon years of experience, general surgery specialty, and preference for more extensive resection were independently associated with greater hospital-level use of radioactive iodine for stage I disease. In addition to surgeon experience and specialty, surgeons' tendency to perform more extensive thyroid resection is associated with greater use of radioactive iodine for stage I thyroid cancer.

Systematic Review of Erosion after Laparoscopic Adjustable Gastric Banding

Erosion of the laparoscopic adjustable gastric band (LAGB) into the lumen of the stomach is a recognised complication of this procedure. We undertook a systematic literature review of the incidence, clinical features and management of erosions occurring after LAGB. A systematic search of relevant medical databases for full-text original articles looking for LAGB patients and reported erosions was conducted. We focussed on incidence, aetiology, clinical presentation, treatment, complications and weight loss. Twenty-five studies of LAGB reported 231 erosions in 15,775 patients (overall incidence of 1.46%). The mean number of patients per study was 631 (±486), and the mean follow-up was 3.73 (±2.4) years. In four reports involving less than 100 patients, there were 27 erosions in a total of 270 patients (10%) compared with 180 erosions in 12,978 patients (1.386%) in the remaining 21 reports. Multiple regression analysis showed that erosion rate was significantly predicted by number of patients and number of years of surgeon experience (r(2) = 0.186). Treatment was most commonly by removal of the band, repair of the stomach and later, band replacement. Other options were removal alone or conversion to another procedure. Weight loss was retained after treatment of the erosion with a mean weight loss at final follow-up of 50.34 ± 3.9 percent excess weight loss. Incidence of erosion after gastric banding is relatively low and can be related to surgeon experience. The most common treatment described in the literature is removal of the eroded band with delayed replacement. Replacement of the band is associated with maintenance of weight loss.

A UK-Wide Survey of Life-Threatening Thyroidectomy Complications

Background and Aims. Complications following thyroidectomy can prolong hospital stay and cause significant morbidity particularly for patients treated for benign thyroid conditions. Our aim was to administer a UK-wide survey of thyroid surgery units on frequency and timing of the onset of life-threatening airway complications & correlate to factors that might be associated with them. Methods. A questionnaire including the number of and timing of the onset of life-threatening airway complications, number of thyroidectomy procedures performed per year, surgeon years of experience, the use of difficult airway management protocol, post-operative patient destination, and patient deaths, was sent to 80 UK surgical units. Results. 23/41 hospitals responded reported no postthyroidectomy airway complications. Life-threatening airways complications all occurred within the first 12 hours postoperatively, with 9 cases occurring in the recovery room and in less than 2 hours, 3 cases occurring 2–6 hours, and 3 cases occurring 6 to 12 hours after surgery. Conclusion. The results may support recent publications that advocate thyroidectomy as a less-than-24-hour surgery procedure in selected patients. Further a larger study and standardised protocol are required to establish patients' selection criteria to determine who are likely to develop serious postoperative complication and may require HDU bed.